The concept of suffering remains elusive in its definition and has different meanings for different patients and their families. For example, at an intuitive level, suffering occurs when individuals find themselves in a difficult situation, for example, having COVID-19, which they would naturally prefer not to have; these are negative states that demand endurance. However, the subjective element in such experiences determines how each individual reacts and copes with the situation and, consequently, the suffering that is perceived. It is equally true that health professionals (including nurses, doctors, researchers, psychotherapists and allied health care professionals) hold different perspectives about suffering. It is because of these varying perspectives that approaches to prevent or manage suffering are diverse. In palliative care, the inevitability of death heightens the prospect of suffering and, with that, comes nursing and medical interventions. It is accepted that relief of suffering is a pre-requisite for all health professionals working in palliative and end-of-life care. However, Nyatanga (2005) argued that, while there remains a lack of consensus on what suffering is, it is not clear what nurses assess as suffering; nurses need to have an understanding first of the nature of suffering and then determine how they ensure that their interventions relieve patients' suffering. Palliative care practices in the UK draw from the principles of palliative care set forth by the World Health Organization (WHO) (1990), and this comment scrutinises the principle of not postponing or hastening death, while arguing that this principle is deeply aligned with preventing suffering.
Postponing or hastening death
At a glance, we can see that the argument to postpone death suggests prolonging life, and inherent with this should also an assessment of the quality of life. Conversely, hastening death translates to cutting life short, and the overriding factor here is also the quality of life. Most experts and families would wish for both (prolonging life and ensuring good quality of life) to be possible, but the challenge is a deteriorating disease condition making such a dual outcome almost always impossible. Interventions such as pain and symptom control go a long way to improving quality of life, but, at the same time, side effects may mean life is neither prolonged nor has enhanced quality. In such cases, it is generally accepted that the overarching ethic of palliative care would favour quality of life as advocated by the Nairobi Hospice Motto ‘put life into their days and not days into their lives’, and can be justified under the principle of beneficence (Mills, 1998). It can be argued that, when quality of life is enhanced, suffering is minimised and, therefore, any futile attempt at treatment is rejected. However, one argument could be that voluntary assisted dying-an active acceleration of death-guarantees maximum quality of life before any pain or suffering occurs, although it is not preferred or legalised in many Western countries, including the UK. This may be explained by the idea of proportionality, which acknowledges that medical advances in pain and symptom control have also made it possible to provide maximum quality of life and prevent suffering, thereby negating the need to legalise voluntary assisted dying. However, the argument that needs pursuing beyond this comment is whether voluntary assisted dying would be acceptable if it was clear that modern medical advances could not relieve intolerable suffering and all it is doing is offer an extension of function rather than quality of life; then, alternative methods might be preferred and can be offered to the patient. The point is that, even with world-class palliative care and medical advances, there is no panacea for suffering that is applicable to all patients. Therefore, it leaves the question of what alternatives are possible.
Rethinking suffering in palliative care would mean nurses and doctors weighing up together with the patient whether the latter prefers prolonging life with intolerable pain or settling for a shorter life without pain. If we accept that pain is a pre-requisite to suffering (Nyatanga, 2005), then we have to also accept that suffering is a more than physical and can be better understood as a psychological phenomenon. With that, the only plausible conclusion is to view suffering as a subjective experience and, as health professionals, we can better understand it by asking the patient about their suffering.